Guidelines For Managing Ambulatory Continuous Peripheral
Nerve Catheters (CPNB)
Vanderbilt University Medical Center
Department of Anesthesiology
Vanderbilt Orthopedic Surgicenter/Acute Pain Service
Start Date- December 1, 2008
Policy Updated- March 13, 2009
1. Continuous Peripheral Nerve Block (CPNB) – Perineural catheter analgesia provides a limb
specific method for profound analgesia following surgery of the upper or lower extremity and
thorax. CPNB involves infusion of local anesthetic at low dosages to provide analgesia
while often sparing motor function. Patient controlled operation of these catheters is
available and should be encouraged. Opioid medications are not used in these infusions and
concurrent oral opioid and other adjuvant analgesics are recommended and encouraged.
Potential drawbacks associated with CPNB include catheter malfunction, infection, local
anesthetic toxicity, and anticoagulation issues with catheter placement or removal (though
anticoagulation is not as great an issues as it is for epidural catheters).
a. Types of Catheters - This policy applies to the use of both nonstimulating catheters
(B-Braun Contiplex) and stimulating catheters (Arrow) placed for either upper or
lower extremity surgery. Wound catheters (eg Iliac crest bone grafts) may also be
managed under this policy.
b. Types of Infusion Pumps – Elastomeric (I-flow) pumps will be employed to deliver
continuous infusion, variable infusion rates, and a patient control bolus for
breakthrough pain.
c. Local Anesthetic- 0.125% Bupivacaine will be used as the local anesthetic of choice
in the pain pumps.
d. Perineural Catheter Infusions Rates - Standard infusion concentrations and rates for
effective analgesia required for the various blocks remains to be elucidated. Using
ropivacaine, providers should aim to stay below 0.5-0.6 mg/kg/hr maximum infusion
rate to guide infusion therapy, particularly with multiple catheters. Patient controlled
techniques (ie “Select a Flow” and/or “On Demand”features) are preferred when
available since these systems usually result in a lower total dose of local anesthetic
and in greater efficacy.
Basal Infusion Rate
6-14 mL/hr
Patient Controlled Bolus and Lockout
4-5ml bolus/30-60min
2. Responsibilities on Day of Surgerya. Attending Surgeon: The attending surgeon should place an order, which allows
anesthesia to be reimbursed for the procedure.
b. Regional Team: Plan for extra time for catheter placement by calling for patients
early and scheduling these cases after first starts in order to maintain OR efficiency.
After informed consent, appropriate CPNBs will be placed most commonly before
surgery in the Block Area. Catheters will be placed with strict sterile technique,
sterilely dressed, and secured. Mastisol and/or dermabond to dry skin with the LockIt system are recommended with catheters, especially with interscalene catheters
which have the highest rate of dislodgement. Rule out intravascular catheters by an
appropriate bolus through the catheter at time of placement or prior to discharge.
c. Attending Anesthesiologist: The attending anesthesiologist will ensure that the box
entitled “Continuous” (eg “Continuous” Femoral Nerve Block) is checked in Gas
Chart, which will initiate the proper reimbursement process.
d. Anesthesiology Resident:
1. NSC: The resident will document the Procedure Note for the CPNB in Star
Panel, using the appropriate CPNB template. The I-Flow Pump Serial #
and Lot #, as well as the Contiplex Catheter/Needle Serial # and Lot#, will
be given to the OR Circulator for proper documentation in VPIMS.
Postoperatively, the patient will be assessed for adequate analgesia and the
dressing should be reassessed and reinforced if necessary. The resident
will fill the pump using sterile technique and initiate the infusion in the
recovery room. The resident will review pump function with the patient
and available family members prior to discharge. The “Patient Instruction
Brochure for Ambulatory CPNBs” will be completed with
anesthesiologists’ names (resident and attending) and the “Outpatient Pain
Service” (OPS) pager number (835-0721) for any questions and concerns.
The resident will ensure OPS coverage when they are unavailable, either
with another regional resident or attending. Finally, the resident will add
the patient name, phone number, catheter type, day of surgery, and surgery
to the OPS white board in the Anesthesia Office (NSC) and to the REDcap
database.
2. Main Hospital: The resident will document the Procedure Note for the
CPNB in Star Panel, using the appropriate CPNB template, and write a
WizOrder for the infusion using the ambulatory pump. In addition, pumps
will be checked out by patient name from the Core Area for appropriate
billing and brought to Pharmacy for filling. Postoperatively, the patient
will be assessed for adequate analgesia and the dressing should be
reassessed and reinforced if necessary. The resident will review pump
function with the patient and available family members prior to discharge.
For CPNBs placed in the Main Hospital, the APS will continue to follow
these catheters until catheter removal; prior to discharge from the Main
Hospital, patients will be given the “Patient Instruction Brochure for
Ambulatory CPNBs” including the anesthesiologists’ names (resident and
attending) and the APS pager number (835-5701) for any questions and
concerns. Finally, patients should remain on the APS Census on WizOrder
until the catheter is removed and remain in the Redcap Database as well.
Careful handoffs between members of the APS Team will ensure that
patients have continuous APS coverage between teams.
e. Pharmacy: At the Main OR, the OR Pharmacy will fill the pump sterilely using
standard protocols and notify anesthesia when available.
f. NSC OR Circulating Nurse: Intraoperatively, the Circulating OR Nurse will include
the I-Flow Pump Serial # and Lot #, as well as the Contiplex Catheter/Needle Serial #
and Lot# in the VPIMS- Intraoperative Nursing Section- Implants.
3. Duration of CPNB Infusions- CPNB infusions should be limited to less than 96 hours,
except for extenuating circumstances on a case by case basis. I-flow pumps cannot be
refilled; if additional duration is needed after a pump runs out, an additional pump will need
to be utilized.
4. Breakthrough Pain – If patients complain of persistent pain > 5/10 despite continuous local
anesthetic infusion, consider managing the patient with oral multimodal therapy (see below)
and/or evaluating the catheter at the surgicenter or hospital. Upon physician evaluation,
several options for troubleshooting are available. Arrow stimulating catheters may be
stimulated to confirm proper position after resolution of the block. The practitioner should
bolus the catheter with 10-20 mL with 1.5% mepivacaine and epinephrine 1:400,000 or
equivalent. If the patient experiences improvement in their pain, the practitioner should
increase the background infusion usually in 2-5 mL increments. If no improvement is
experienced, the catheter should be considered incorrectly positioned and be removed. (N.B.
Significant pain deep to the catheter sight has been associated with a deep catheter infection
and should be part of the differential diagnosis, particularly for catheters of > 72hrs duration.)
5. Multimodal Therapy: While advanced regional anesthesia techniques may significantly
diminish acute pain, patients undergoing extensive surgery, particularly those who are
opioid-tolerant, may require multimodal analgesia in addition to CPNBs. Consider adding
the following analgesics as appropriate:
a. Short –acting Opioids: Most patients will be given short-acting oral opioids, most
commonly hydrocodone or oxycodone, 5-10mg tablets, usually in a preparation
which includes 325-500mg of acetaminophen. With a daily acetaminophen
maximum of 4000 mg, a patient may take up to 8 tablets of the short-acting
combination meds per day safely.
b. NSAID’s: After discussing with the surgeon, adding NSAID of your choice (eg
Meloxicam 7.5-15mg po qd) will diminish the opiate requirement. Avoid traditional
NSAID’s in patients with a history of gastritis, renal dysfunction, and/or bleeding
diathesis. Celebrex (100-200mg bid), a COX-2 inhibitor, offers some advantages
including less risk of gastritis, no platelet inhibition, and reduced central
sensitization.
c. Long-acting Opioids: Challenging acute pain patients may require a short course of
long-acting agents, such as oxycontin 10-20mg po bid or methadone 5-10mg po tid.
Initiate therapy with the lowest possible dosing with the intent to discontinue therapy
after the catheter is discontinued.
d. Other: Co-administration of other agents, including clonidine 0.1-0.2mg po bid, as
well as anticonvulsants (eg gabapentin 300-600mg po tid) can be effective in
reducing opioid requirements, particularly in opioid-tolerant patients, in the acute
pain setting.
6. Catheters and anticoagulation – Deep peripheral nerve catheters (eg lumbar plexus or
paravertebral catheters) should not be placed or removed during periods of significant anticoagulation. Our guideline for low molecular weight heparin is not to place or remove deep
catheters within 12 hours of the last dose.
7. Responsibility for Follow-up of Patients –
a. Nashville Surgery Center Patients: The Orthopedic Surgicenter Team will provide
care for all OPS patients. The Regional resident(s) will review with the attending
anesthesiologist any existing ambulatory CPNBs and maintain the REDcap database.
The REDcap database and the OPS White Board will allow the various
anesthesiologists to effectively follow patients and note any changes made. Daily
evaluation of each patient will most commonly be telephonic but can be in person at
the surgicenter depending on the needs of the patient. Clinical care will be
documented in Star Panel on a daily basis using the APS Encounter Note template.
The Attending Anesthesiologist will discuss the care with the resident and attest each
of the Star Panel notes. If patients need to be evaluated in person after hours, the
patient will be instructed to come to the PACU or Emergency Room of the Main
Hospital for evaluation there by the OPS team. (We anticipate that the need to
provide in-person after hours care to be very infrequent; if the after hours care is
simply to pull a catheter, this duty may be delegated to the VUH Call resident or APS
team if mutually agreeable.)
b. APS Patients: - The APS Team will provide care for all APS patients. The Regional
resident(s) will review with the attending anesthesiologist any existing ambulatory
CPNBs and maintain the APS Census and the REDcap database. The REDcap
database will allow the various anesthesiologists to effectively follow patients and
note any changes made. Daily evaluation of each patient will most commonly be
telephonic but can be in person at the hospital depending on the needs of the patient.
Clinical care will be documented in Star Panel on a daily basis using the APS
Encounter template. The Attending Anesthesiologist will discuss the care with the
resident and attest each of the Star Panel notes. If patients need to be evaluated in
person after hours, the patient will be instructed to come to the PACU or Emergency
Room of the Main Hospital for evaluation there by the APS team. (We anticipate that
the need to provide in-person after hours care to be very infrequent; if the after hours
care is simply to pull a catheter, this duty may be delegated to the VUH Call resident
if mutually agreeable.)
8. Review of Program –
Review of procedures and patient outcomes will be reviewed monthly by the Medical
Director of the Orthopedic Surgicenter and the Acute Pain Service Director, and reported
at the respective POD meetings. Revisions to this policy will be completed as necessary
to ensure the highest degree of patient safety, satisfaction, and outcomes.
Questions and concerns regarding the policy can be addressed to:
Randall J. Malchow, MD
Associate Professor, Anesthesiology
Medical Director, Vanderbilt Orthopedic Surgicenter
Rajnish Gupta, MD
Assistant Professor, Anesthesiology
Associate Director, Vanderbilt Adult Acute Pain Service